Provider Demographics
NPI:1427435015
Name:CRUZ, AUDREY SUE LEGASPI (MD)
Entity type:Individual
Prefix:
First Name:AUDREY SUE
Middle Name:LEGASPI
Last Name:CRUZ
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6355 S BUFFALO DR FL 3
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89113-2133
Mailing Address - Country:US
Mailing Address - Phone:702-216-3346
Mailing Address - Fax:702-671-6883
Practice Address - Street 1:8595 S DECATUR BLVD STE 108
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89139-7006
Practice Address - Country:US
Practice Address - Phone:702-948-1130
Practice Address - Fax:702-688-8861
Is Sole Proprietor?:Yes
Enumeration Date:2015-05-03
Last Update Date:2022-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA145334207R00000X
NV20673207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV1427435015Medicaid
NV20673OtherSTATE LICENSE